Cost Of Quality-adjusted Life Years Research Articles

Cognitive Remediation Works But How Should We Provide It? An Adaptive Randomized Controlled Trial of Delivery Methods Using a Patient Nominated Recovery Outcome in First-Episode Participants.

Cognitive remediation (CR) benefits cognition and functioning in psychosis but we do not know the optimal level of therapist contact, so we evaluated the potential benefits of different CR modes. A multi-arm, multi-center, single-blinded, adaptive trial of therapist-supported CR. Participants from 11 NHS early intervention psychosis services were independently randomized to Independent, Group, One-to-One, or Treatment-as-usual (TAU). The primary outcome was functional recovery (Goal Attainment Scale [GAS]) at 15-weeks post randomization. Independent and TAU arms were closed after an interim analysis, and three informative contrasts tested (Group vs One-to-One, Independent vs TAU, Group + One-to-One vs TAU). Health economic analyses considered the cost per Quality Adjusted Life Year (QALY). All analyses used intention-to-treat principles. We analyzed 377 participants (65 Independent, 134 Group, 112 One-to-One, 66 TAU). GAS did not differ for Group vs One-to-One: Cohen's d: 0.07, -0.25 to 0.40 95% CI, P = .655; Independent vs TAU: Cohen's d: 0.07, -0.41 to 0.55 95% CI, P = .777. GAS and the cognitive score improved for Group + One-to-One vs TAU favoring CR (GAS: Cohen's d: 0.57, 0.19-0.96 95% CI, P = .003; Cognitive score: Cohens d: 0.28, 0.07-0.48 95% CI, P = .008). The QALY costs were £4306 for Group vs TAU and £3170 for One-to-One vs TAU. Adverse events did not differ between treatment methods and no serious adverse events were related to treatment. Both active therapist methods provided cost-effective treatment benefiting functional recovery in early psychosis and should be adopted within services. Some individuals benefited more than others so needs further investigation. ISRCTN14678860 https://doi.org/10.1186/ISRCTN14678860Now closed.

Pharmacoeconomic evaluation of the tixagevimab and cilgavimab combination using for pre-exposure prophylaxis of COVID-19

To evaluate pharmacoeconomic feasibility using of the tixagevimab and cilgavimab combination for pre-exposure prophylaxis of COVID-19 in immunocompromised patients. Cost-effectiveness of tixagevimab and cilgavimab in persons ≥12 years old who weigh ≥40 kg and have either a history of allergy that prevents their vaccination against COVID-19 or moderate or immunocompromised was assessed based on PROVENT phase III study results. The quantity of life years or quality-adjusted life years gained was calculated. Direct medical cost associated with prophylaxis of COVID-19, treatment of infected patients and those experiencing long COVID post infection were assessed. Results were compared with wiliness-to-pay threshold, measured as tripled gross domestic product per capita and equal to 2.69 mln RUB in 2022. Pre-exposure prophylaxis of COVID-19 results in additional 0.0287 life years or 0.0247 quality-adjusted life years. The cost of additional life year gained is equal to 1.12 mln RUB, the cost of additional quality-adjusted life years is 1.30 mln RUB. Both costs of additional life year and cost of quality-adjusted life years appeared to be significantly less compared to wiliness-to-pay threshold. Pre-exposure prophylaxis of COVID-19 with combination of tixagevimab and cilgavimab is economically feasible and may be recommended for wide use in Russian healthcare system.

Cost-utility of venoarterial extracorporeal membrane oxygenation in cardiogenic shock and cardiac arrest.

The use of venoarterial extracorporeal membrane oxygenation in cardiogenic shock keeps increasing, but its cost-utility is unknown. We studied retrospectively the cost-utility of venoarterial extracorporeal membrane oxygenation in a five-year cohort of consequent patients treated due to refractory cardiogenic shock or cardiac arrest in a transplant centre in 2013-2017. In our centre, venoarterial extracorporeal membrane oxygenation is considered for all cardiogenic shock patients potentially eligible for heart transplantation, and for selected postcardiotomy patients. We assessed the costs of the index hospitalization and of the one-year hospital costs, and the patients' health-related quality of life (response rate 71.7%). Based on the data and the population-based life expectancies, we calculated the amount and the costs of quality-adjusted life years gained both without discount and with an annual discount of 3.5%. The cohort included 102 patients (78 cardiogenic shock; 24 cardiac arrest) of whom 67 (65.7%) survived to discharge and 66 (64.7%) to one year. The effective costs per one hospital survivor were 242,303€. Median in-hospital costs of the index hospitalization per patient were 129,967€ (interquartile range 150,340€). Mean predicted number of quality-adjusted life years gained by the treatment was 20.9 (standard deviation 9.7) without discount, and the median cost per quality-adjusted life year was 7474€ (interquartile range 10,973€). With the annual discount of 3.5%, 13.0 (standard deviation 4.8) quality-adjusted life years were gained with the cost of 12,642€ per quality-adjusted life year (interquartile range 15,059€). We found the use of venoarterial extracorporeal membrane oxygenation in refractory cardiogenic shock and cardiac arrest justified from the cost-utility point of view in a transplant centre setting.

A Comparative Study of the Cost and Uptake of Community Pharmacy "Stop Smoking and Emergency Contraception" Services from the Perspective of the National Health Service.

Objective:The objective was to explore if the community pharmacy (CP) stop smoking service (SSS) and emergency hormonal contraception patient group direction (EHC PGD) meet the needs of the English population and are cost-effective.Methods:This research was completed over 2 years. Public health resources provided details of CPs and provision of SSS and EHC PGD. Questionnaires were sent to smoking cessation/sexual health leads in local authorities to obtain information not available elsewhere. Questionnaires inquired about CP payment for provision of SSS and EHC PGD, overhead costs, successful outcomes, and validation methods. Quit rates at 4-weeks, 52-weeks, and lifetime determined SSS effectiveness. The effectiveness of EHC PGD was based on the probability of unintended pregnancy with/without levonorgestrel. Incremental cost-effectiveness ratio and cost of quality-adjusted life years (QALYs) gained were calculated. Descriptive statistics were determined. A priori of less than 0.05 (P < 0.05) was significant.Findings:SSS provision and uptake did not match local needs (smoking prevalence) even though increased CP SSS provision correlated with increased SSS success. Similarly, the need (based on teenage pregnancy rates) for EHC PGD did not correlate with the rate of CP provision but only with the uptake. Nevertheless, the provision of SSS and EHC PGD from CPs was cost-effective from an NHS perspective. Various assumptions were tested, but in all cases fell well below NICE QALY recommendations for cost-effectiveness.Conclusion:Provision of SSS and EHC PGD from CP does not meet the needs of the population even though the delivery of these services is cost-effective.

Contemporary Context of Drug-Eluting Stents in Brazil: A Cost Utility Study.

Although drug-eluting stents (DES) have been widely incorporated into clinical practice in developed countries, several countries restrict their use mainly because of their high cost and unfavorable incremental cost-effectiveness ratios (ICER). To evaluate the cost-effectiveness of DES in comparison with bare-metal stents (BMS) for treatment of coronary artery disease (CAD). Markov model. Published literature, government database, and CAD patient cohort. Single-vessel CAD patients. One year and lifetime. Brazilian Public Health System (SUS). Six strategies composed of percutaneous intervention with a BMS or 1 of 5 DES (paclitaxel, sirolimus, everolimus, zotarolimus, and zotarolimus resolute). Cost for target vessel revascularization avoided and cost for quality-adjusted life year gained. In the short-term analysis, sirolimus was the most effective and least costly among DES (ICER of I$20,642 per target vessel revascularization avoided), with all others DES dominated by sirolimus. Lifetime cumulative costs ranged from I$18,765 to I$21,400. In the base case analysis, zotarolimus resolute had the most favorable ICER among the DES (ICER I$62,761), with sirolimus, paclitaxel, and zotarolimus being absolute dominated and everolimus extended dominated by zotarolimus resolute, although all the results were above the willingness-to-pay threshold of 3 times the gross domestic product per capita (I$35,307). In deterministic sensitivity analysis, results were sensitive to cost of DES, number of stents used per patient, baseline probability, and duration of stent thrombosis risk. The probabilistic sensitivity analysis demonstrated a probability of 81% for BMS being the strategy of choice, with 9% for everolimus and 9% zotarolimus resolute, at the willingness-to-pay threshold. DES is not a good value for money in SUS perspective, despite its benefit in reducing target vessel revascularization. Since the cost-effectiveness of DES is mainly driven by the stents' cost difference, they should cost less than twice the BMS price to become a cost-effective alternative.

Targeted temperature management: a health economic perspective

More and more limited financial resources in the health care sector call for an economic evaluation of potential new therapies. The economic evaluation of a new therapy is complex and depends not only on the perspective of the various stakeholders, but also on the country-specific characteristics of various reimbursement systems. From the patient perspective, the costs for new therapies might not be a concern, as long as the insurance system covers the costs. From the hospital perspective, a new therapy which reduces the length of stay might be worthwhile in a DRG-based reimbursement system, but not in a pay-per-patient-day reimbursement system. To respect the perspective of the society, a cost-effectiveness analysis could be expressed in terms of a ratio where the denominator is a gain in quality-adjusted life years (QALY) and the numerator is the cost associated with the health gain. QALY is a measure of disease burden and takes into account the quality of life measured as the Health Utility Index (HUI, dead = 0 and perfect health = 1) and quantity of life lived measured as survival time: QALY = survival time × HUI (for example, 4 years survival with HUI 0.5 = 2 QALY, or 2 years survival with HUI 1 = 2 QALY). Previous studies reported that mild therapeutic hypothermia improves neurologic recovery and survival in patients resuscitated from cardiac arrest. The estimated number needed to treat is only six patients; nevertheless, target temperature management has hardly been implemented in post-cardiac arrest treatment. The aim of the current study was to evaluate the cost-effectiveness of therapeutic hypothermia in post-cardiac arrest patients. The QALY–cost ratio was chosen as the primary outcome. To assess the cost-effectiveness of temperature management, data from a Cochrane review about mild hypothermia after cardiac arrest including 398 patients were analyzed. The QALY–cost ratio was calculated based on the cerebral performance score and total treatment costs after cardiac arrest. The assumed costs included potential cooling procedure, hospital stay, rehabilitation, and potential defibrillation implantation in Austria. Total treatment costs per 100 patients were €4.1 million for patients treated with mild hypothermia, and €3.7 million for patients with standard care. Post-arrest patients receiving mild hypothermia gained an average of 1.11 QALY compared with conventional care. This resulted in a cost-effectiveness ratio of €3.827 per QALY. Targeted temperature management at 32 to 34°C after cardiac arrest seems to be a very cost-effective treatment, with €3.827 per QALY far below commonly used benchmarks for assessing the cost-effectiveness of an intervention. These results may provide an economic rationale for implementing targeted temperature management as a standard treatment after cardiac arrest.

Catheter-Directed Thrombolysis for Acute Deep Vein Thrombosis: A Cost-effectiveness Analysis

Abstract SESSION TYPE: DVT/PE/Pulmonary Hypertension Posters IPRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PMPURPOSE: Deep vein thrombosis (DVT) remains associated with substantial morbidity. Post-thrombotic syndrome (PTS) often complicates acute DVT and may lead to major symptoms that limit quality of life (QoL). Catheter-directed thrombolysis (CDT) has recently been shown to reduce the risk for PTS. However, PTS is invasive, costly, and may result in major bleeding. Therefore, we performed a decision analysis in order to determine if CDT is cost-effective.METHODS: We created a decision model in which patients with acute DVT were managed with or without CDT. The model examined outcomes in 1,000 hypothetical subjects and all were treated with similar anticoagulation strategies with the exception of CDT. The costs of saving one added quality-adjusted life-year (QALY) in our reference case represented the primary endpoint. Model inputs were derived from the literature and all costs were converted to 2010 US dollars. We assumed a societal perspective. We conducted univariate and multivariate sensitivity analyses to assess the robustness of our assumptions. We relied on Monte-Carlo simulation to generate 95% confidence intervals (CIs) around our point estimate of the cost-effectiveness ratio (CER).RESULTS: In the base case scenario the CER equaled $104,394/QALY. Nearly three-quarters of all the costs in the CDT arm were due to the direct costs of CDT. CDT generated nearly 52 added QALYs compared to standard care. The marginal cost to prevent one case of PTS measured $57,309. The model was most sensitive to the estimated risk reduction (RR) for PTS with CDT. Ranging the RR for PTS with CDT around the 95% CIs for this variable yielded CERs varying from approximately $52,000/QALY to $1.7m/QALY saved. The model was mildly sensitive to the impact of PTS on QoL and the costs of CDT. In the worst case scenario with all variables simultaneously skewed against CDT, the cost for QALY came to more than $7.7m/QALY saved. The 95% CIs around the base case CER varied from $144,202 to $89,165. Few simulations fell below the $100,000/QALY threshold.CONCLUSIONS: Although CDT may significantly reduce the risk for PTS following acute DVT, this approach is not cost-effective. The limited impact of CDT and uncertainty surrounding its efficacy elucidate why this approach proves cost-ineffective.CLINICAL IMPLICATIONS: CDT should not be considered a routine adjunct to care for acute DVT.DISCLOSURE: The following authors have nothing to disclose: C. Chan, M. Zilberberg, G. Lamare, A. ShorrNo Product/Research Disclosure InformationWashington Hospital Center, Washington, DC.

Milan criteria in liver transplantation for hepatocellular carcinoma: An evidence-based analysis of 15 years of experience

Hepatocellular carcinoma (HCC) is the seventh most common cancer worldwide and the third most common cause of cancer-related deaths; the number of new cases per year is approaching 750,000. The magnitude of the incidence of HCC has discouraged any attempts to apply liver transplantation (LT) as the prevailing curative therapy for HCC worldwide because of the limited sources of donated organs (deceased and living donors) and the poor access to sophisticated health care systems in some geographical areas. If these limitations continue to prevail throughout the world, any attempt to significantly reduce HCC-related mortality rates through the application of LT will be delusional. International experiences have confirmed, however, the potential of LT to definitively cure HCC because it presents a unique opportunity to remove both the tumor (HCC is associated with 695,000 deaths per year) and the underlying cirrhosis. Despite its limited access, LT has become the standard of care for patients with small HCCs and the main driving force for alternative strategies offered to patients with intermediate HCCs. In 1996, a prospective cohort study defined restrictive selection criteria that led to superior survival for transplant patients in comparison with any other previous experience with transplantation or other options for HCC. Since then, these selection criteria have become universally known as the Milan criteria (MC) in recognition of their origin. Ever since their adoption in clinical practice, the MC have helped doctors to single out early-stage HCC as a prognostic category of cancer presentation that is amenable to curative treatments. After their implementation, the favorable posttransplant outcomes that were observed in cohort series were so convincing that the MC immediately became the standard of care for early HCC, and further validation by randomized controlled trials (RCTs) was prevented. After the passage of approximately a decade, researchers began to challenge the MC with other proposals designed to capture those patients not meeting the MC who could achieve similar posttransplant survival rates through the expansion of the accepted tumor limits for transplant eligibility. None of these expanded criteria have become the new reference standard for selecting LT candidates with HCC; any broadening of the selection criteria for transplantation is inevitably hampered by severe

PERFECT preterm infant study

Introduction. This article summarizes the main findings of the preterm infant sub-study of the Performance, Effectiveness and Costs of Treatment episodes (PERFECT) study. We studied effects of birth hospital level and time of birth on mortality and morbidity and cost-effectiveness of care of very low gestational age (VLGA)/very low birth weight (VLBW) infants.Material and Methods. The study included all infants born below 32 weeks or 1501 g in Finland in 2000–2007. Different cohorts were used depending on the time point.Results. The one-year mortality of live-born VLBW/VLGA infants was higher if born in level II versus level III hospitals, or if born during out-of-office hours in level II versus office hours in level III hospitals. Two out of three VLGA/VLBW subjects did not have any of the prematurity-related morbidities studied. The average cost of quality-adjusted life years was €19,245 by four years of age; the cost was higher in VLGA/VLBW infants with long-term morbidities.Discussion. Birth in a level III hospital improved survival of VLGA/VLBW infants. Results suggest inadequate overnight competence in small hospitals. Despite high initial costs, care of VLGA/VLBW infants was already cost-effective by four years of age. Cost-effectiveness can be improved by reducing long-term morbidities.

Long-term cost-effectiveness of weight management in primary care

As obesity prevalence and health-care costs increase, Health Care providers must prevent and manage obesity cost-effectively. Using the 2006 NICE obesity health economic model, a primary care weight management programme (Counterweight) was analysed, evaluating costs and outcomes associated with weight gain for three obesity-related conditions (type 2 diabetes, coronary heart disease, colon cancer). Sensitivity analyses examined different scenarios of weight loss and background (untreated) weight gain. Mean weight changes in Counterweight attenders was -3 kg and -2.3 kg at 12 and 24 months, both 4 kg below the expected 1 kg/year background weight gain. Counterweight delivery cost was pound59.83 per patient entered. Even assuming drop-outs/non-attenders at 12 months (55%) lost no weight and gained at the background rate, Counterweight was 'dominant' (cost-saving) under 'base-case scenario', where 12-month achieved weight loss was entirely regained over the next 2 years, returning to the expected background weight gain of 1 kg/year. Quality-adjusted Life-Year cost was pound2017 where background weight gain was limited to 0.5 kg/year, and pound2651 at 0.3 kg/year. Under a 'best-case scenario', where weights of 12-month-attenders were assumed thereafter to rise at the background rate, 4 kg below non-intervention trajectory (very close to the observed weight change), Counterweight remained 'dominant' with background weight gains 1 kg, 0.5 kg or 0.3 kg/year. Weight management for obesity in primary care is highly cost-effective even considering only three clinical consequences. Reduced healthcare resources use could offset the total cost of providing the Counterweight Programme, as well as bringing multiple health and Quality of Life benefits.

Longitudinal changes in quality of life and costs in long-term survivors of tumors of the oropharynx treated with brachytherapy or surgery

Purpose Based on earlier studies we were interested in finding out if longitudinal assessment of quality of life (QoL) and costs in long-term survivors of oropharyngeal cancers treated with external beam radiation therapy and brachytherapy (BT) or surgery and postoperative radiotherapy showed a change in QoL over the years. Besides, we were curious to know how much the costs per life year and the QALY would be for this patient group. Methods and materials Performance status scales: eating in public, understandability of speech, normalcy of diet, xerostomia and ability to swallow were determined in 2003 and 2005. In 2005, the responses to EORTC QLQ-C30, EORTC H&N35, and the Euroqol questionnaire were also measured. Costs and quality-adjusted life years (QALYs) were calculated. Results Eating in public, understandability of speech, and normalcy of diet significantly differed in favor of BT. Surgical patients experienced more speech, teeth, and mouth-opening problems. Mean costs and QALYs for BT were €16,112 and €56,060 and for surgery €26,590 and €93,275, respectively. Conclusions QoL scores don't change over time. Due to the number of admission days, surgery is more costly. Difference in costs for QALYs in favor of BT was observed.

Intrathecal baclofen therapy in children with intractable spastic cerebral palsy: a cost‐effectiveness analysis

In a Dutch national study, we recently established the effectiveness and safety of continuous intrathecal baclofen infusion (CITB) in children with intractable spastic cerebral palsy (CP). Because prospective studies on the cost-effectiveness of CITB in children with spastic CP are lacking, we conducted a cost-effectiveness analysis alongside our prospective national study. We compared the costs and health effects of CITB with those of standard treatment only, from the health care perspective for a 1-year period. Health effects were expressed in terms of a visual analogue scale for individual problems and quality-adjusted life years (QALYs). We included eight females and seven males, aged between 7 and 17 years (mean age 13y 8mo [SD 3y]). Eleven children had spastic CP and four had spastic-dyskinetic CP. One child was clsssified on the Gross Motor Function Classification System at Level III, two at Level IV, and 12 at Level V. CITB was more effective and more costly than standard treatment only. Gaining one QALY cost on average 32,737 euros. We conclude that based on the threshold-willingness to pay for one QALY in the Netherlands (80,000 euros), our results confirm the cost-effectiveness of CITB for carefully selected children with intractable spastic CP.

Cost-Utility Analysis: A Method of Quantifying the Value of Registered Nurses

Cost-utility analysis is one method of determining the cost effectiveness of nursing interventions. It is heralded by the World Health Organization as the measure to determine allocation of resources. This method of measurement includes calculation of both the cost of quality-adjusted life years (QALY) and the cost of disability-adjusted life years (DALY). The purpose of this article is to present cost-utility analysis as a relevant measure for describing the value of registered nurses. First the article will present a short overview of cost effectiveness, along with a discussion of two cost-effectiveness measures, cost-effective analysis and cost-utility analysis. Then the measurement of quality-adjusted life years and disability-adjusted life years will be presented. The article will conclude by challenging nurses to develop cost-utility analyses into a meaningful and useful methodology that can provide nursing with a process to measure the economic outcomes of our nursing interventions.

Costs Are Not the Only Thing We Should Be Concerned with in Anesthesia

In Response: We thank Dr. Bloomfield for his comments on our paper. Indeed, the economic evaluation of a medical procedure is complex. Our aim was to estimate cost differences between different anesthesia techniques and analyze the cost drivers behind them. To calculate the long-term economic impact of medical treatments and procedures is a very important, but very tricky, task. To calculate the cost of quality-adjusted life years for specific anesthesia procedures, as Dr. Bloomfield suggests, might be very difficult given the complex interaction of surgical and anesthesiological complications and the low morbidity and mortality achieved by modern anesthesia science. We absolutely agree that we will need much more solid data both on outcomes and on costs before we are able to realize such a long-term assessment of anesthesia techniques. Martin Schuster, MD, MA Andre Gottschalk, MD Thomas Standl, MD Department of Anesthesiology University Hospital Hamburg-Eppendorf Hamburg, Germany [email protected]

997 ORAL Results of intensity modulated radiotherapy (IMRT) in laryngeal and hypopharyngeal cancer: A dose escalation study

Based on earlier studies we were interested in finding out if longitudinal assessment of quality of life (QoL) and costs in long-term survivors of oropharyngeal cancers treated with external beam radiation therapy and brachytherapy (BT) or surgery and postoperative radiotherapy showed a change in QoL over the years. Besides, we were curious to know how much the costs per life year and the QALY would be for this patient group.Performance status scales: eating in public, understandability of speech, normalcy of diet, xerostomia and ability to swallow were determined in 2003 and 2005. In 2005, the responses to EORTC QLQ-C30, EORTC H&N35, and the Euroqol questionnaire were also measured. Costs and quality-adjusted life years (QALYs) were calculated.Eating in public, understandability of speech, and normalcy of diet significantly differed in favor of BT. Surgical patients experienced more speech, teeth, and mouth-opening problems. Mean costs and QALYs for BT were €16,112 and €56,060 and for surgery €26,590 and €93,275, respectively.QoL scores don't change over time. Due to the number of admission days, surgery is more costly. Difference in costs for QALYs in favor of BT was observed.